text: Background The Military Health System is responsible for, among other things, assuring the overall oral health of all uniformed DOD personnel. As part of this health system, each service’s dental corps provides dental care for its servicemembers. The Army, the Navy, and the Air Force Dental Corps include approximately 3,000 active duty dentists and approximately 247 (200 in the United States) dental clinics to serve over 1.3 million servicemembers. Unlike their medical counterparts, the services’ dental corps rarely provide beneficiary care, according to service officials. The primary role of military dentists is to ensure the oral health and readiness of servicemembers. Servicemembers’ oral health is evaluated using standardized measures to determine the extent to which they are deployable. Generally, servicemembers with identified urgent, emergent, or unknown dental treatment needs are not considered to be worldwide deployable until their oral health is adequately addressed. Becoming a Military Dentist Most military dentists enter service through the Armed Forces’ Health Professions Scholarship Program (AFHPSP), a scholarship program available to students enrolled in or accepted to dental school. Under the services’ AFHPSP program, DOD pays for tuition, books, and fees, and provides a monthly stipend. In return, the students incur an obligation to serve 6 months of active duty service for each 6 months of benefits received, with a 2-year minimum obligation. AFHPSP dental students can pursue either a Doctor of Dental Surgery or Doctor of Dental Medicine degree to become a general dentist. In addition to the AFHPSP program, the services recruit fully qualified licensed dentists. For example, individuals may become military dentists through direct accessions, either by entering the service as a fully trained, licensed dentist or through the Financial Assistance Program, which provides stipends for dentists accepted or enrolled in a residency program. For additional information on these and other recruitment programs, see appendix I. Regardless of the recruitment program, dentists may begin to practice after obtaining a degree and completing licensure requirements. Military dentists may pursue postgraduate training through a general dentistry program, such as the Advanced Education in General Dentistry Program, a general practice residency, or a specialty dental program offered through the Uniformed Services University of the Health Sciences Postgraduate Dental College. Postgraduate dental college includes training and/or residency within a specific specialty and typically requires between 1 to 6 years of additional training. While in a postgraduate dental college program, participants incur an additional 6 months of active duty service obligation for each 6 months in training, with a minimum of 2 years active duty service obligation. However, this obligation can be served concurrently with obligations already incurred through AFHPSP if incurred through sponsored postgraduate education in a military or affiliated program. Figure 1 portrays the path to becoming a military dentist and the active duty obligation incurred for AFHPSP dental students. Each service takes steps to validate whether the military dentist has the appropriate professional qualifications and clinical abilities. Validation includes ensuring the dentist is credentialed and privileged to practice. See appendix II for more details on service processes for monitoring qualification and performance of dentists. Roles and Responsibilities for the Recruitment and Retention of Military Dentists The Assistant Secretary of Defense for Health Affairs (ASD(HA)) serves as the principal advisor for all DOD health policies and programs. The ASD(HA) issues DOD instructions, publications, and memorandums that implement policy approved by the Secretary of Defense or the Under Secretary of Defense for Personnel and Readiness and governs the management of DOD medical programs. The ASD(HA) also exercises authority, direction, and control over the President of the Uniformed Services University of the Health Sciences (USUHS). Further, ASD(HA) sets the special and incentive pay amounts for all military dentists. The ASD(HA) reports to the Under Secretary of Defense for Personnel and Readiness, who in turn reports to the Secretary of Defense. The Army, the Navy, and the Air Force medical commands and agencies report through their service chiefs to their respective military department secretaries and then to the Secretary of Defense. The Army, the Navy, and the Air Force have the authority to recruit, train, and retain dentists. Each military service has its own organizational structure and responsibilities. See figure 2. In September 2013, the Defense Health Agency was established to support greater integration of clinical and business processes across the Military Health System. The Defense Health Agency, among other things, manages the execution of policies issued by the ASD(HA) and manages and executes the Defense Health Program appropriation, which funds the services medical departments. By no later than September 30, 2021, the Director of the Defense Health Agency will assume responsibility for the administration of each military treatment facility, to include budgetary matters, information technology, and health care administration and management, among other things. Although military treatment facilities include dental clinics, DOD initially intended to exclude dental care (except oral and maxillofacial surgery), from the transfer to the Defense Health Agency. However, as of September 2018, DOD stated it is assessing the extent to which dental care will fall under the Defense Health Agency’s administration. GAO’s Prior Work on Military Treatment Facility Staffing Models and Tools In July 2010, we found that the services’ collaborative planning efforts to determine staffing of medical personnel working in fixed military treatment facilities, including dentists, were limited, and that their staffing models and tools had not been validated and verified in all cases as DOD policy requires. Specifically, we found that some Army specialty modules contained outdated assumptions, and that only a portion of the models had been completely validated. We also found that the Navy did not have a model, but instead employed a staffing tool that used current manning as a baseline and adjusted its requirements based on emerging needs or major changes to its mission. However, the Navy’s tool was not validated or verified in accordance with DOD policy. Further, we found that the Air Force may not know its true medical requirements because the model it relied on also was not validated or verified. We made several recommendations in our 2010 report, two of which were aimed at improving staffing of MTFs. Specifically, we recommended that the services identify common medical capabilities shared across military treatment facilities and develop and implement cross-service medical staffing standards for these capabilities as appropriate. We also recommended that each service update or develop medical personnel requirements determination tools as needed to ensure that they use validated and verifiable processes. The Army, the Navy, and the Air Force have implemented our recommendation related to the development and implementation of validated and verifiable tools for developing medical personnel requirements. Additionally, they identified and developed standardized cross-service staffing standards for over 40 medical specialties and incorporated them into their individual MTF staffing tools. Two of Three Services Use Validated Dental Clinic Staffing Models, and None of the Models Incorporate Cross- Service Standards The Army and the Air Force Use Validated Dental Clinic Staffing Models, and the Navy’s Proposed Model Is under Review The Army and the Air Force have validated the dental clinic staffing models that they use, and the Navy’s draft model is under review. In the absence of a validated model, the Navy uses a general ratio to staff its dental clinics. See table 1 for a description of each of the services’ methodology for staffing dental clinics. The Army and the Air Force models, which were developed in accordance with DOD guidance and service-specific requirements, are subject to the following validation processes: Army. Since 2011, the Army has used the Army Dental Clinic Model, which, according to officials, is intended to determine the minimum number of dentists necessary, by location, to ensure the medical readiness of soldiers. Army staffing models are subject to validation by the U.S. Army Manpower Analysis Agency, which validated the Army’s Dental Clinic Model when it was developed in 2011. According to an Army official, the model’s validation expired in 2014, and was not re-validated until May 2018 due to limited resources. Additionally, Army officials stated that the data used in the model are updated on an annual basis and that the model is subject to revalidation every 5 years. Air Force. Since 2014, according to Air Force officials, the Air Force has used its Dental Manpower Model to determine the minimum number of dentists required, by clinic, to ensure the medical readiness of servicemembers served by Air Force dental clinics. According to Air Force officials, the Air Force Dental Manpower Model is subject to review and validation that includes input from the Air Force Medical Service; Surgeon General’s Manpower, Personnel, and Resources office; Air Force Personnel Center; and consultants. Officials told us the model is reviewed and validated annually and presented to the Dental Operations Panel and Air Force’s medical service corporate structure. The model was most recently validated in April 2018. According to Navy Bureau of Medicine and Surgery (BUMED) officials, the Navy does not yet have a model and therefore instead uses a general ratio of one dentist for every 1,000 sailors as a baseline to initially determine the staffing requirements of its dental clinics. This ratio is adjusted based upon emerging needs or major changes to mission. In 2013, according to Navy officials, BUMED began developing a Dental Services Model that could be used to determine dental clinic staffing needs. In November 2016, BUMED internally released a draft report recommending that the dental corps approve and implement the Dental Services Model as the staffing standard for dental clinics. According to a Navy official, this report was provided to dental corps leadership for review in July 2018 and they are expected to complete their review in October 2018. According to BUMED officials, if the dental corps leadership approves the model for use as an official staffing standard, the model would be subject to official Navy validation processes which, in accordance with DOD policy, would entail verification and validation throughout the model’s lifecycle. Conversely, if the dental corps decides to use the model as an informal staffing tool to supplement its current processes, a BUMED official stated that it will be subject to an ad-hoc internal review every 3 years that mirrors the Navy’s review of its validation process. The Services Have Not Developed Cross-Service Staffing Standards for Dental Care Currently, the Army, the Navy and the Air Force each use different service-specific standards and other factors to determine the number of dentists needed at their respective dental clinics. As previously discussed, the services have developed and are in the process of implementing cross-service staffing standards—that is, a standardized approach to staffing the common day-to-day health needs of the patient population—for certain medical specialties. In response to DOD policy and our 2010 recommendation, the services established a working group to identify and develop common cross-service staffing standards, and in 2017, the tri-service working group established such standards for 42 different medical specialties. These standards are based on actual workload data for common capabilities within selected medical specialties and were incorporated into each service’s staffing tools to provide consistent values for the minimum number of staff required to meet patient needs. However, according to an official involved in the development of the standards, the services have not collaborated to develop a plan to establish a similar set of standards for dental care. DOD guidance directs modeling and simulation management to develop plans and procedures and to pursue common and cross-cutting modeling tools and data across the services. Also, the ASD(HA) has supported the effort to establish consistent workload drivers across services for determining personnel requirements for MTFs. According to a tri-service working group co-chair, they did not develop cross-service staffing standards for dental care because at the time, the quality of available data on dental procedure frequency and duration varied across the services. The same official stated that these data have been improved, but they still do not have plans to develop cross-service staffing standards for dental care. Additionally, service officials maintained that they must operate their respective dental clinics autonomously and in a manner that best supports their service-specific needs and unique command structures. Specifically, officials from each service’s dental corps stated that their primary mission is focused on the medical readiness of servicemembers and generally does not involve beneficiary care. As such, they have not collaborated on staffing efforts with the other services. While we recognize that each service operates under a different command structure, readiness requirements for oral health are standardized across DOD, and all servicemembers are required to meet the same level of oral health in order to be deployable. Additionally, since DOD is currently assessing whether it will consolidate the services’ dental corps staff under the Defense Health Agency’s administration, it remains unclear to us why dental care has been excluded from cross- service efforts to develop a common set of standards for staffing military dental clinics—especially because the services have developed common staffing standards for42 other medical specialties. The Services Generally Have Met Goals for Recruiting Dental Students, but Not for Fully Qualified Dentists and Do Not Know the Extent to Which Certain Programs Are Effective at Helping Recruit and Retain Dentists The Army, the Navy, and the Air Force have generally met their recruitment goals for dental students, but generally have not met their recruitment goals for fully qualified dentists to address oral health needs of the services. Overall, we found that the services maintained their staffing levels for military dentists during fiscal years 2012 through 2016, but experienced gaps within certain specialties. Further, the services rely on various programs and special pays and incentives, to recruit and retain military dentists, but they do not know the extent to which some of these programs are effective at helping them to do so. The Services Generally Met Recruitment Goals for Dental Students, but Faced Challenges Recruiting Fully Qualified Dentists Our analysis of Army, Navy, and Air Force data found that in fiscal years 2012 through 2016, the services generally met their goals for dental students recruited through the Armed Forces Health Professions Scholarship Program (AFHPSP). From fiscal year 2012 through fiscal year 2016, the Army met 94 percent of its goals, the Navy met 100 percent of its goals, and the Air Force met 97 percent of its goals. Figure 3 shows the AFHPSP recruitment goals and achievements, by service for fiscal years 2012 through 2016. To address their immediate need for dental providers, the services also recruit fully qualified general dentists or specialists. However, the services have experienced challenges meeting their recruitment goals for fully qualified dentists. Figure 4 below shows the recruitment goals and achievements for fully qualified dentists from fiscal years 2012 through 2016. As shown in the figure, the Army did not meet its recruitment goals for 5 consecutive years, the Navy did not meet its goals for 2 of these 5 years, and the Air Force did not meets its goals for 3 of these 5 years. While the services have experienced challenges in recruiting fully qualified dentists, the challenges are most pronounced in certain specialties. For example, based on our analysis of service data from fiscal years 2012 through 2016, the Army and the Navy were unable to recruit any oral surgeons and the Air Force recruited 50 percent of the oral surgeons it needed. Service officials cited various reasons for not being able to meet their recruitment goals for certain specialties, including the availability of more lucrative careers in the private sector and quality of life concerns associated with military service, such as frequent moves. Additionally, Air Force officials stated that they are not always able to offer accession bonuses consistently, which has caused challenges in recruiting. Table 2 shows the recruitment goals and percentage achieved for fully qualified dentists, by specialty, from fiscal years 2012 through 2016. The Services Have Maintained Overall Staffing Levels for Military Dentists, but Have Experienced Challenges Retaining Certain Specialties While the services maintained overall staffing levels for military dentists, they have experienced some challenges retaining certain specialties. Overall, military dentist end strengths—the actual number of dentists on board at the end of the fiscal year—have generally met or exceeded dental authorizations. Specifically, between fiscal years 2012 and 2016, the Army’s dental authorizations were filled, on average, at about 109 percent, the Navy’s at about 101 percent, and the Air Force’s at about 97 percent. Further, DOD data show that average overall gain rates are equal to average overall loss rates for the services’ dental corps in fiscal years 2012 through 2015 at approximately 10 percent for the Army, 9 percent for the Navy, and 11 percent for the Air Force. Additionally, according to our analysis of Army and Navy data, on average, approximately 73 percent of Army dentists continue on active duty after 5 years of service, and approximately 63 percent of Navy dentists continue on active duty after 5 years of service. According to Air Force officials, the Air Force does not routinely track data on the number of dentists that continue on active duty after 5 years of service. Although the services have been able to maintain their overall numbers for the total number of dentists in their respective dental corps, we found, based on the data the services provided us, that each service experienced gaps in certain dental specialties, including critically short wartime specialties. For example, all of the services experienced gaps in comprehensive dentistry from fiscal years 2012 through fiscal year 2016. In addition, for the same time period, all of the services experienced gaps in prosthodontists and oral surgeons. Officials from all three services cited family concerns, frequent moves, and competition from the private sector as reasons why these and other dentists choose to leave the military. Additionally, Army and Navy officials cited limited training and education opportunities and limited scope of practice as reasons why specialists such as oral surgeons leave the military. The Services Monitor Their Recruitment and Retention Programs, but Do Not Know Whether The Programs Are Effective The services rely on programs, such as AFHPSP, the Critical Wartime Skills Accession Bonus (CWSAB), and special pay and incentives, to attract and retain military dentists, but they do not know the extent to which some of these programs are effective at helping them meet their recruiting and retention goals. Our prior work on effective strategic workforce planning principles concluded that agencies should periodically measure their progress toward meeting human capital goals. These principles state that measuring the extent that human capital activities contribute to achieving programmatic goals provides information for effective oversight by identifying performance shortfalls and appropriate corrective actions. Further, according to these principles, agencies should develop use of flexibilities and other human capital strategies that can be implemented with the resources that can be reasonably expected to be available, and should consider how these strategies can be aligned to eliminate gaps. Additionally, Standards for Internal Control in the Federal Government states that management should monitor internal control systems, through ongoing monitoring and evaluations. According to these standards, evaluations should be used to provide feedback on the effectiveness of ongoing monitoring and should be used to help design systems and determine effectiveness. The standards also provide that management should determine the appropriate corrective actions to address any identified deficiencies upon completing its evaluation. According to Army, Navy, and Air Force officials, the services have taken various actions to monitor their recruitment and retention programs. For example, officials told us that they review recruitment goals, achievements, and retention rates; conduct workforce planning and modeling; and participate in recruitment and retention working groups. Specifically, Army officials stated that they use forecasts from a 5-year management plan to determine the Army’s recruiting mission and review its continuation rates to assess retention of dentists. Navy officials told us that they review annual recruitment goals and track whether they are meeting those goals on a weekly basis. Air Force officials stated that they participate in the Medical Accessions Working Group three times per year to assess ongoing recruitment activities. While the services monitor their progress toward recruitment and retention goals, they do not know the extent to which the programs designed to help them meet their goals affect their ability to recruit and retain dentists because they have not evaluated their effectiveness. For example, DOD Directive 1304.21 allows the services to use accession bonuses to meet their personnel requirements and specifies that bonuses are intended to influence personnel inventories in specific situations in which less costly methods have proven inadequate or impractical. The services have the discretion to issue up to $20,000 as an accession bonus under the AFHPSP—in addition to paying full tuition, education expenses, and a monthly stipend. In fiscal years 2012 through 2016, the Army and the Navy offered the accession bonus and generally met their recruitment goals—an achievement that Army officials credit, in part, to their use of the incentive. Specifically, Army officials told us that prior to using the bonus in 2009, they were not meeting their recruitments goals. They also expressed concern that, if they were to discontinue use of the bonus, they would not be able to meet their current goals. Conversely, Air Force officials told us that they stopped offering the bonus in 2012 because the number of AFHPSP applicants had exceeded the number of AFHPSP positions; the Air Force has continued to meet its recruiting goals without the use of the bonus. An Air Force official acknowledged that not offering the bonus could result in their losing potential applicants to the services that do offer the bonus, but Air Force officials also recognized that money is not always a deciding factor for those who choose to serve as a dentist in the military. The uncertainty described by the Army and Air Force officials demonstrates their lack of information about what factors motivate individuals to join the military. Moreover, the differing use of the accession bonus by the two services with similar outcomes indicates that the services do not know when it is necessary to use the recruiting tool because they have not evaluated the effectiveness of this program. Another bonus the services can offer is the CWSAB, which ranges from $150,000 for general dentists to $300,000 for comprehensive dentists, endodontists, prosthodontists, and oral maxillofacial surgeons, to individuals entering the military as a dentist in a critically short wartime specialty. While a bonus can be offered to any dental specialty designated as a critically short wartime specialty, data that we analyzed indicate that the bonus may be disproportionately effective in recruiting for these specialties. For example, from fiscal years 2012 through 2016, the Navy used this type of bonus and was able to meet or exceeded its recruitment goals for critically short wartime specialty general dentists and staffed this specialty at between 108 and 122 percent. However, our analysis of the Navy’s data also found that, even after offering this bonus, the Navy was unable to recruit any oral surgeons during the same time period. However, like with the accession bonus, service officials do not know the extent to which the CWSAB bonus is an effective recruitment incentive for some or all of the critically short wartime specialties because they have not evaluated the effectiveness of this program. In addition, the services offer special pay and incentives, which vary by specialty, to qualified dentists. Special pay and incentives include incentive pay, retention bonuses, and board certification pay. Each bonus and incentive, except board certification pay, requires an additional service obligation, thus creating a retention tool for the services. The services and officials from the Office of the ASD(HA) participate in the Health Professions Incentives Working Group to review recruitment and retention special pay and incentives and recommends adjustment to amounts offered as necessary. Service and officials from the Office of the ASD(HA) told us that there are no ways to evaluate the effectiveness of these incentives because they cannot account for the emotional or non- monetary decisions that contribute to whether servicemembers stay in the military, and money is not always an effective incentive for getting people to train in certain specialties or to continue their service. However, in our recent review of DOD’s special pay and incentive programs in 2017, we recommended that DOD take steps to improve the effectiveness of its special pay and incentive programs. Additionally, in February 2018, through our review of gaps in DOD’s physician specialties, we recommended that the services develop targeted and coordinated strategies to alleviate military physician gaps. An official from the Office of the ASD(HA) stated that they have started discussing measures with the services to evaluate the effectiveness of DOD’s medical and dental recruitment and retention programs, including special pay and incentives. Additionally, Office of ASD(HA) and service officials stated that they will begin reviewing the dental special pays and incentives in fiscal year 2019. Because these reviews are in the early stages, it is too soon to know how effective they will be in evaluating pay and incentive programs. Although service officials also told us that they believe their recruitment and retention programs are effective because they have generally met their overall recruiting and retention goals, until the services evaluate the effectiveness of their recruitment and retention efforts, they will not have the information to know which programs are the most efficient and cost- effective. Conclusions DOD continues to implement several major initiatives to support the mission of its health system maintaining the medical readiness of servicemembers while operating as efficiently as possible. The dental corps plays a critical role in these efforts by ensuring the oral health and dental readiness of all servicemembers. Ensuring dental readiness requires, in part, that the services are able to staff dentists adequately and consistently across DOD’s dental clinics. However, the Army, the Navy, and the Air Force have not collaborated in their approaches to staffing dental clinics, and have not developed cross-service staffing standards for dental clinic staffing. As DOD progresses in its efforts to implement efficiencies across its Medical Health System and assesses the scope of medical care to be transferred to the Defense Health Agency, it could be of benefit to the dental corps to develop cross-service standards that could result in improvements to the consistency and efficiency of dental clinic staffing. In addition to ensuring the appropriate number of dentists at each clinic to support the dental corps’ mission, recruiting and retaining fully qualified dentists has been an ongoing challenge for the services. However, the services have not evaluated whether their existing programs have been effective at helping them recruit and retain dentists, and therefore do not know whether they are effectively targeting their resources to address the most significant recruitment and retention challenges. Recommendations for Executive Action We are making a total of six recommendations, including two to the Army, two to the Navy, and two to the Air Force. Specifically: The Secretary of the Army should ensure that the Surgeon General of the Army Medical Command (1) collaborate with the Navy Bureau of Medicine and Surgery and the Air Force Medical Service to develop a common set of planning standards to be used to help determine dental clinic staffing needs, and (2) incorporate these standards into the Army’s dental corps staffing model. (Recommendation 1) The Secretary of the Navy should ensure that the Surgeon General of the Navy Bureau of Medicine and Surgery (1) collaborate with the Army Medical Command and the Air Force Medical Service to develop and implement a common set of planning standards to be used to help determine dental clinic staffing needs, and (2) incorporate these standards into the Navy’s dental corps staffing model. (Recommendation 2) The Secretary of the Air Force should ensure that the Surgeon General of the Air Force Medical Service (1) collaborate with the Army Medical Command and the Navy Bureau of Medicine and Surgery to develop and implement a common set of planning standards to be used to help determine dental clinic staffing needs, and (2) incorporate these standards into the Air Force’s dental corps staffing model. (Recommendation 3) The Secretary of the Army should ensure that the Surgeon General of the Army Medical Command evaluates the effectiveness of its recruitment and retention programs for military dentists, including the need for and effectiveness of the recruitment and retention incentives currently offered. (Recommendation 4) The Secretary of the Navy should ensure that the Surgeon General of the Navy Bureau of Medicine and Surgery evaluates the effectiveness of its recruitment and retention programs for military dentists, including the need for and effectiveness of the recruitment and retention incentives currently offered. (Recommendation 5) The Secretary of the Air Force should ensure that the Surgeon General of the Air Force Medical Service evaluates the effectiveness of its recruitment and retention programs for military dentists, including the need for and effectiveness of the recruitment and retention incentives currently offered. (Recommendation 6) Agency Comments We provided a draft of this report to DOD for review and comment. DOD did not provide comments. DOD did provide us with technical comments, which we have incorporated, as appropriate. We are sending copies of this report to the appropriate congressional committees, the Secretary of Defense, the Under Secretary of Defense for Personnel and Readiness, the Office of the Assistant Secretary of Health Affairs, the Secretaries of the Army, the Navy, the Air Force, and the President of the Uniformed Services University of the Health Sciences. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-3604 or FarrellB@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III. Appendix I: Military Dentist Accession Programs and Incentives In addition to the Department of Defense’s (DOD) Armed Forces Health Professions Scholarship Program, DOD uses several other programs and incentives to recruit military dentists. Table 3 includes a selection of DOD’s military dentist accession programs and incentives. Appendix II: The Services’ Mechanisms to Monitor Qualifications and Performance of Military Dentists DOD policy requires that all military dentists must be credentialed and privileged to practice dentistry. Credentialing is the process of inspecting and authenticating the documentation to ensure appropriate education, training, licensure, and experience. Privileging is the corresponding process that defines the scope and limits of practice for health care professionals based on their relevant training and experience, current competence, peer recommendations, and the capabilities of the facility where they are practicing. According to officials, the services have developed and implemented processes to continuously monitor dentist performance in accordance with DOD policy. According to officials, the services monitor military dentist performance through On-Going Professional Practice Evaluations (OPPE) and Focused Professional Practice Evaluations (FPPE). The OPPE is a continuous evaluation of dentist performance that reviews six dimensions of performance: (1) patient care, (2) medical knowledge, (3) professionalism, (4) practice-based learning and improvement, (5) interpersonal and communication skills, and (6) systems-based practice. The FPPE is a process of periodic evaluation by the dental clinic of the specific competence of a dentist performing procedures and administering care. FPPEs are conducted during a dentist’s initial appointment, when granting new privileges, or if a question arises about a dentist’s ability to provide, safe, high quality patient care. In addition to the performance monitoring required by DOD, according to officials, the Army and the Air Force have instituted their own mechanisms for monitoring the quality and performance of their dentists. Army: According to officials, the Army monitors dental quality through its quarterly Continuous Quality Management Program. This program includes the review of data related to records audits, infection control, radiation protection, utilization management, implant reports, drug utilization reports, patient safety events, and risk management. According to officials, these reviews are intended to identify and address any errors or trends in dental care. Air Force: According to officials, annually, Air Force dentists must document that they have reviewed and will follow the Air Force Medical Service Dental Clinical Practice Guidelines. According to officials, this ensures that all dentists are following the same standard of care for dental treatment. Additionally, according to officials, Air Force dentists participate in a peer review process known as Clinical Performance Assessment and Improvement. According to officials, in this process, a licensed peer dentist preferably of the same specialty reviews the dentist’s practice and procedures. Further, according to officials, depending on the nature of issues found during the review, corrective actions—ranging from refresher courses to a loss of license and credentials—may be taken. Appendix III: GAO Contact and Staff Acknowledgments GAO Contact Acknowledgments In addition to the contact named above, Kimberly Mayo, Assistant Director; Nicole Collier; Alexandra Gonzalez; Amie Lesser; Tida Barakat Reveley; Rachel Stoiko; John Van Schaik; Lillian Yob; and Elisa Yoshiara made key contributions to this report. Related GAO Products Defense Health Care: Additional Assessments Needed to Better Ensure an Efficient Total Workforce. GAO-18-102, Washington, D.C.: Nov. 27, 2018. Defense Health Care: DOD Should Demonstrate How Its Plan to Transfer the Administration of Military Treatment Facilities Will Improve Efficiency. GAO-19-53, Washington, D.C.: Oct. 30, 2018. Defense Health Care: Expanded Use of Quality Measures Could Enhance Oversight of Provider Performance. GAO-18-574, Washington, D.C.: Sept. 17, 2018. Military Personnel: Additional Actions Needed to Address Gaps in Military Physician Specialties. GAO-18-77. Washington, D.C.: Feb. 28, 2018. Defense Health Reform: Steps Taken to Plan the Transfer of the Administration of the Military Treatment Facilities to the Defense Health Agency, but Work Remains to Finalize the Plan, GAO-17-791R. Washington, D.C.: Sept. 29, 2017. Military Compensation: Additional Actions Are Needed to Better Manage Special and Incentive Pay Programs. GAO-17-39. Washington, D.C.: Feb. 3, 2017. Defense Health Care Reform: DOD Needs Further Analysis of the Size, Readiness, and Efficiency of the Medical Force. GAO-16-820. Washington, D.C.: Sept. 21, 2016. Defense Health Care: Additional Information Needed about Mental Health Provider Staffing Needs. GAO-15-184. Washington, D.C.: Jan. 30, 2015. Human Capital: Additional Steps Needed to Help Determine the Right Size and Composition of DOD’s Total Workforce. GAO-13-470. Washington, D.C.: May 29, 2013 Defense Health Care: Actions Needed to Help Ensure Full Compliance and Complete Documentation for Physician Credentialing and Privileging. GAO-12-31. Washington, D.C.: Dec. 15, 2011. Military Cash Incentives: DOD Should Coordinate and Monitor Its Efforts to Achieve Cost-Effective Bonuses and Special Pays. GAO-11-631. Washington, D.C.: June 21, 2011. Military Personnel: Enhanced Collaboration and Process Improvements Needed for Determining Military Treatment Facility Medical Personnel Requirements. GAO-10-696. Washington, D.C.: Jul. 29, 2010. Military Personnel: Status of Accession, Retention, and End Strength for Military Medical Officers and Preliminary Observations Regarding Accession and Retention Challenges. GAO-09-469R. Washington, D.C.: Apr. 16, 2009. Military Personnel: Better Debt Management Procedures and Resolution of Stipend Recoupment Issues Are Needed for Improved Collection of Medical Education Debts, GAO-08-612R. Washington, D.C.: Apr. 1, 2008. Primary Care Professionals: Recent Supply Trends, Projections, and Valuation of Services. GAO-08-472T. Washington, D.C.: Feb. 12, 2008. Military Physicians: DOD’s Medical School and Scholarship Program. GAO/HEHS-95-244. Washington, D.C.: Sept. 29, 1995. Defense Health Care: Military Physicians’ Views on Military Medicine. GAO/HRD-90-1. Washington, D.C.: Mar. 22, 1990.
target: DOD has taken steps to modernize its Military Health System to ensure that it operates efficiently. For example, in September 2013, the Defense Health Agency was created, in part, to implement common clinical and business processes across the services. Essential to this effort are the services' ability to effectively staff their medical facilities, including the processes used for staffing dental clinics and the services' ability to recruit and retain military dentists. Senate Report 115-125 included a provision for GAO to review the services' processes for determining requirements for dentists and its programs for recruiting and retaining military dentists, among other things. GAO assessed the extent to which the services (1) use validated dental clinic staffing models that also incorporate cross-service staffing standards, and (2) have recruited and retained military dentists and measured the effectiveness of their recruitment and retention programs. GAO assessed service dental clinic models, analyzed recruitment and retention data from fiscal year 2012 through 2016, and interviewed DOD and service officials. The Army and the Air Force use validated staffing models for their respective dental clinics, and the Navy has developed a model that is under review. The Army and the Air Force's models are based on service-specific staffing standards. For example, the Army's model generally projects dental clinic staffing based on historical facility data and, according to officials, the Air Force model is largely a population-based model that requires one dentist for every 650 servicemembers. In contrast, in the absence of a validated model, officials stated that, the Navy uses a general ratio of one dentist for every 1,000 servicemembers to staff its dental clinics. The Navy has developed a model that is under review, and if approved, according to officials, will be subject to the Navy's validation processes. While the services have developed and implemented cross-service staffing standards for 42 medical specialties, according to a key official involved in developing these standards, they currently do not plan to develop a similar set of standards for dental care. Cross-service staffing standards help the services standardize clinic staffing to address the common day-to-day health needs of patients. Service officials maintain that they must operate their respective dental clinics autonomously and in a manner that best supports their service-specific needs and unique command structures. However, as oral health requirements for servicemembers are standardized across the Department of Defense (DOD), it is unclear why dental care has been excluded from the staffing standardization effort—especially because the services have implemented cross-service staffing standards for 42 other medical specialties. The Army, the Navy, and the Air Force meet their needs for military dentists by recruiting both dental students and fully qualified dentists. The services generally met their recruitment goals for dental students between fiscal years 2012 and 2016, but faced challenges recruiting and retaining fully qualified dentists during that period. For example, the Army missed its recruitment goals for fully qualified dentists in all 5 years, the Navy missed its goals in 2 out of 5 years, and the Air Force missed its goals in 3 out of 5 years. These challenges are most pronounced for certain specialties. For example, service data indicate that the Army and the Navy were unable to recruit any oral surgeons, while the Air Force recruited 50 percent of the oral surgeons it needed. Service officials cited various reasons for not meeting recruitment goals, including the availability of more lucrative careers in the private sector and quality of life concerns associated with military service. The services rely on various programs, including scholarships and special pay and incentives, to attract and retain military dentists, and service officials stated that they monitor their programs by reviewing their goals, among other actions. However, GAO found that some services continue to provide incentive bonuses for positions that are overstaffed and have met or exceeded recruitment goals, but they do not know whether this is necessary because they have not evaluated the effectiveness of their programs. Without evaluating their programs, the services lack the information necessary to ensure that they are using recruitment and retention incentives effectively and efficiently for attracting and retaining dentists.